<div>
<form action="">
<fieldset><legend>Select</legend>
<table width="100%" cellpadding="5px" cellspacing="20px">
	<tr>
		<td>Monthly Gross Income</td>
		<td><input type="text" value="18,000"/></td>
	</tr>
	<tr>
		<td>Net Income</td>
		<td></td>
	</tr>
</table>
</fieldset>
</form>
</div>
<div></div>